SOAP Note for COPD Exacerbation

Subjective

Cardinal symptoms to assess: Increased dyspnea, increased sputum volume, and increased sputum purulence 1, 2
Document number of cardinal symptoms present (determines antibiotic indication) 1
Quantify baseline functional status and degree of worsening 1
Assess for triggers: recent respiratory infection, medication non-adherence, environmental exposures 1
Review smoking status and exacerbation frequency over past year 1

Vital signs: Respiratory rate, oxygen saturation (target SpO2 88-92%), heart rate, blood pressure 1
Physical examination findings: Use of accessory muscles, wheezing, prolonged expiration, decreased breath sounds, signs of respiratory distress 1
Arterial blood gas: Mandatory within 1 hour if oxygen initiated to assess for hypercapnia and acidosis 1, 3
Chest radiograph: Rule out pneumonia, pneumothorax, heart failure 2
Laboratory tests: Complete blood count, electrolytes, blood eosinophil count (predicts corticosteroid response) 1
ECG: Assess for cardiac complications 2

COPD exacerbation severity classification:

Mild: Increased symptoms only, manageable at home 3
Moderate: Requires antibiotics and/or oral corticosteroids 3
Severe: Requires hospitalization or emergency department evaluation; may have acute respiratory failure 3

Start short-acting beta2-agonists (SABA) combined with short-acting anticholinergics (SAMA) immediately 1, 2, 3

Administer via nebulizer (preferred for hospitalized patients as easier to use) or metered-dose inhaler with spacer 1, 3
Initial dosing upon arrival, then every 4-6 hours; may use more frequently if needed 1, 2
Combination therapy provides superior bronchodilation compared to either agent alone 3
Avoid methylxanthines (theophylline) due to increased side effects without added benefit 1, 3

Administer prednisone 40 mg orally once daily for exactly 5 days 1, 2, 3

Oral route equally effective as intravenous; use oral unless patient cannot tolerate 1, 3
Do not exceed 5-7 days duration 1, 2, 3
Improves lung function, oxygenation, shortens recovery time and hospitalization duration 1, 2
May be less effective in patients with low blood eosinophil counts 1, 3

Prescribe antibiotics for 5-7 days if patient has:

First-line antibiotic choices: 1, 3

Alternative antibiotics: Newer cephalosporins, macrolides (azithromycin), or quinolones based on local resistance patterns 1, 3, 4

Initiate controlled oxygen to achieve SpO2 88-92% 1, 2

Start with FiO2 ≤28% via Venturi mask or 2 L/min via nasal cannula in known COPD patients 2
Mandatory arterial blood gas within 1 hour to ensure adequate oxygenation without CO2 retention or worsening acidosis 1, 3

Initiate noninvasive ventilation (NIV) as first-line for acute hypercapnic respiratory failure 1, 2, 3

NIV reduces intubation rates, mortality, hospitalization duration, and improves gas exchange 1, 2
Success rate 80-85% when appropriately selected 1
Invasive mechanical ventilation reserved for NIV failure 1

Initiate or optimize maintenance therapy with long-acting bronchodilators (LAMA, LABA, or combination) before discharge 3
Schedule pulmonary rehabilitation within 3 weeks post-discharge to reduce readmissions and improve quality of life 3
Smoking cessation counseling at every visit 1, 3
Review inhaler technique 1
Provide action plan for future exacerbations 3
Follow-up visit within 4-6 weeks as 20% of patients have not recovered to baseline at 8 weeks 3

Do not use ipratropium as monotherapy for acute exacerbation; faster-acting agents preferred initially 5
Do not extend corticosteroids beyond 5-7 days; no additional benefit and increases adverse effects 1, 2
Do not start pulmonary rehabilitation during hospitalization; increases mortality; wait until post-discharge 3
Do not forget arterial blood gas after initiating oxygen to avoid unrecognized hypercapnia 1, 3